1992, The British Journal of Radiology, 65, 442^44 Economic Community. I. Introduction, objectives and activities. Magnetic Resonance Imaging, 6, 175-178. REDPATH, T. W., 1982. Calibration of the Aberdeen NMR imager for proton spin-lattice relaxation time measurements in vivo. Physics in Medicine and Biology, 27, 1057-1065. RICHARDS, M. A., GREGORY, W. M., WEBB, J. A. W., JEWELL,
S. E. & REZNEK, R. H., 1987. Reproducibility of spin-lattice relaxation time (T,) measurement using an 0.08 tesla MD800 magnetic resonance imager. British Journal of Radiology, 60, 241-244. SMITH, M. A. & TAYLOR, D. G., 1986. The absence of tissue
specificity in MRI using in vivo Tx or T2 determination: true
Technical notes biological variation or technical artefact? British Journal of Radiology, 59, 82-83. WALKER, P. M., LERSKI, R. A., MATHUR-DE VRE, R., BINET, J.
& YANE, F., 1988. Identification and characterisation of biological tissues by NMR. Concerted research project of the European Economic Community. VI. Preparation of agarose gels as reference materials for NMR relaxation time measurement. Magnetic Resonance Imaging, 6, 215-222. WALKER, P. M., BALMER, C , ABLETT, S. & LERSKI, R. A., 1989.
A test material for tissue characterisation and system calibration in MRI. Physics in Medicine and Biology, 34,
5-22.
The disappearing bladder—modifying imaging techniques after rectal excision By W. C. G. Peh, FRCR, N. C. Chokshi, FRCR and *C. H. Young, FRCS Departments of Diagnostic Radiology and "Urology, Selly Oak Hospital, Birmingham B29 6JD, UK (Received 5 July 1991, accepted 3 October 1991) Keywords: Bladder diseases, Pelvic surgery, Rectal surgery, Urinary outflow obstruction
Urological complications after abdomino-perineal excision of the rectum are well recognized. One complication is chronic urinary retention, which occurs in 14-50% of patients (Watson & Williams, 1952; Buckwalter et al, 1955; Eickenberg et al, 1976; Neal et al, 1982; Watters et al, 1983). The three main theories explaining causes of bladder dysfunction are direct nerve injury, loss of bladder support and pericystitis (Buckwalter et al, 1955; Eickenberg et al, 1976). Vesical neuropathy is now generally accepted as the main cause of urinary retention and this has been reflected in the emphasis on urodynamic studies, conducted mostly by urologists (Rankin, 1969; Fowler, 1973; Fowler et al, 1978; Neal et al, 1982; Chang & Fan, 1983; Lupton, 1986). We present two male patients who developed posterior—inferior bladder prolapse subsequent to rectal excision and illustrate the modifications of standard imaging technique required to demonstrate the altered anatomy.
sacrum. An intravenous urogram (IVU) examination was done and on the frontal projection, the bladder was noted to have an abnormal shape. The bladder also appeared to be in a low position (Fig. 1). A lateral projection done with the patient
Case 1 A 65-year-old man presented with persistent discomfort and a feeling of fullness in the perineal region. He subsequently had difficulty in micturition and poor stream. Abdomino-perineal excision for rectal carcinoma had been done 9 years previously. Cystoscopy was normal. Computed tomography (CT) scan demonstrated a prolapsed bladder lying posteriorly against the Address correspondence to Dr Wilfred C. G. Peh, Department of Diagnostic Radiology, University of Hong Kong, Queen Mary Hospital, Hong Kong.
442
Figure 1. IVU—frontal view shows abnormal position of a misshapen bladder. The British Journal of Radiology, May 1992
Technical notes
Figure 3. Ultrasound using the perineal approach demonstrates bladder prolapse.
Figure 2. IVU—erect lateral view shows posterior and inferior bladder prolapse.
standing erect showed abnormal descent of the bladder inferiorly and posteriorly (Fig. 2). This finding was confirmed at operation where the bladder was found herniated through the pelvic floor. Reduction and repair were performed with improvement of urinary symptoms.
with normal micturition. In women, however, bladder displacement is slight and the intact anterior vaginal wall is believed to provide support to the urethra (Watson & Williams, 1952). An erect lateral film in the IVU series is both a simple and cheap way of demonstrating the bladder position. Similarly, using the perineal approach for ultrasound is not difficult and may demonstrate an otherwise elusive bladder. Besides patients who have had abdomino-perineal excision of the rectum, other groups in which these modified techniques could be applied include those with major gynaecological exenterative surgery and panpro tocolectomies. Demonstration of abnormal bladder prolapse as the cause of urinary problems, especially in males, would be helpful in planning corrective surgery.
Case 2 A 68-year-old man presented with difficulty in micturition. He had intermittent poor stream and found that applying upwards pressure by hand to the perineum aided voiding. He had an abdomino-perineal excision for rectal carcinoma 3 years previously. Despite repeated attempts, the bladder could not be demonstrated by ultrasound with the transducer placed conventionally on the anterior abdominal wall. However, with the transducer placed perineally near the site of the former anal opening, the bladder was easily visualized (Fig. 3).
Discussion
In these two cases, inferior and posterior bladder prolapse is likely to have occurred owing to a combination of factors, such as severance of ligaments supporting the bladder, creation of a potential space by rectal excision and herniation of the bladder through a weakened or damaged pelvic floor. Indeed, post-mortem specimens have shown posterior displacement of the whole bladder, including the bladder base and prostate after abdomino-perineal excision. Buckwalter et al (1955) postulated that these changes, accompanied by angulation of the bladder neck and urethra, resulted in mechanical interference Vol. 65, No. 773
References BUCKWALTER, J. A., SHROPSHIRE, R. & JOINER, B. A.,
1955.
Morbidity of abdominoperineal resection. Surgery, Obstetrics & Gynecology, 101, 483-488. CHANG, P. L. & FAN, H. A., 1983. Urodynamic studies before and/or after abdominoperineal resection of the rectum for carcinoma. Journal of Urology, 130, 948-951. EICKENBERG, H., AMIN, M., KLOMPUS, W. & LICH, R.,
1976.
Urological complications following abdominoperineal resection. Journal of Urology, 115, 180-182. FOWLER, J. W., 1973. Bladder function following abdominoperineal excision of the rectum for carcinoma. British Journal of Surgery, 60, 574-576. FOWLER, J. W.,
BREMNER, D. N. & MOFFAT, L. E. F.,
1978.
The incidences and consequences of damage to the parasympathetic nerve supply to the bladder after abdominoperineal resection of the rectum for carcinoma. British Journal of Urology, 50, 95-98. LUPTON, E. W., 1986. Management of urinary outflow obstruction after pelvic surgery: a review. Journal of the Royal Society of Medicine, 79, 734-737. NEAL, D. E M PARKER, A. J., WILLIAMS, N. S. & JOHNSTON, D.,
1982. The long term effects of proctectomy on bladder function in patients with inflammatory bowel disease. British Journal of Surgery, 69, 349-352.
443
Technical notes RANKIN, J. T., 1969. Urological complications of rectal surgery.
WAITERS, G. R., BOKEY, E. L., CHAPUIS, P. H., MAHER, P. W.
British Journal of Urology, 41, 655-659. WATSON, P. C. & WILLIAMS, D. I., 1952. The urological complications of excision of the rectum. British Journal of Surgery, 40, 19-28.
& PHEILS, M. T., 1983. Urological complications following abdominoperineal excision of the rectum for carcinoma. Australasian & New Zealand Journal of Surgery, 53,445-447.
444
The British Journal of Radiology, May 1992
S. E. & REZNEK, R. H., 1987. Reproducibility of spin-lattice relaxation time (T,) measurement using an 0.08 tesla MD800 magnetic resonance imager. British Journal of Radiology, 60, 241-244. SMITH, M. A. & TAYLOR, D. G., 1986. The absence of tissue
specificity in MRI using in vivo Tx or T2 determination: true
Technical notes biological variation or technical artefact? British Journal of Radiology, 59, 82-83. WALKER, P. M., LERSKI, R. A., MATHUR-DE VRE, R., BINET, J.
& YANE, F., 1988. Identification and characterisation of biological tissues by NMR. Concerted research project of the European Economic Community. VI. Preparation of agarose gels as reference materials for NMR relaxation time measurement. Magnetic Resonance Imaging, 6, 215-222. WALKER, P. M., BALMER, C , ABLETT, S. & LERSKI, R. A., 1989.
A test material for tissue characterisation and system calibration in MRI. Physics in Medicine and Biology, 34,
5-22.
The disappearing bladder—modifying imaging techniques after rectal excision By W. C. G. Peh, FRCR, N. C. Chokshi, FRCR and *C. H. Young, FRCS Departments of Diagnostic Radiology and "Urology, Selly Oak Hospital, Birmingham B29 6JD, UK (Received 5 July 1991, accepted 3 October 1991) Keywords: Bladder diseases, Pelvic surgery, Rectal surgery, Urinary outflow obstruction
Urological complications after abdomino-perineal excision of the rectum are well recognized. One complication is chronic urinary retention, which occurs in 14-50% of patients (Watson & Williams, 1952; Buckwalter et al, 1955; Eickenberg et al, 1976; Neal et al, 1982; Watters et al, 1983). The three main theories explaining causes of bladder dysfunction are direct nerve injury, loss of bladder support and pericystitis (Buckwalter et al, 1955; Eickenberg et al, 1976). Vesical neuropathy is now generally accepted as the main cause of urinary retention and this has been reflected in the emphasis on urodynamic studies, conducted mostly by urologists (Rankin, 1969; Fowler, 1973; Fowler et al, 1978; Neal et al, 1982; Chang & Fan, 1983; Lupton, 1986). We present two male patients who developed posterior—inferior bladder prolapse subsequent to rectal excision and illustrate the modifications of standard imaging technique required to demonstrate the altered anatomy.
sacrum. An intravenous urogram (IVU) examination was done and on the frontal projection, the bladder was noted to have an abnormal shape. The bladder also appeared to be in a low position (Fig. 1). A lateral projection done with the patient
Case 1 A 65-year-old man presented with persistent discomfort and a feeling of fullness in the perineal region. He subsequently had difficulty in micturition and poor stream. Abdomino-perineal excision for rectal carcinoma had been done 9 years previously. Cystoscopy was normal. Computed tomography (CT) scan demonstrated a prolapsed bladder lying posteriorly against the Address correspondence to Dr Wilfred C. G. Peh, Department of Diagnostic Radiology, University of Hong Kong, Queen Mary Hospital, Hong Kong.
442
Figure 1. IVU—frontal view shows abnormal position of a misshapen bladder. The British Journal of Radiology, May 1992
Technical notes
Figure 3. Ultrasound using the perineal approach demonstrates bladder prolapse.
Figure 2. IVU—erect lateral view shows posterior and inferior bladder prolapse.
standing erect showed abnormal descent of the bladder inferiorly and posteriorly (Fig. 2). This finding was confirmed at operation where the bladder was found herniated through the pelvic floor. Reduction and repair were performed with improvement of urinary symptoms.
with normal micturition. In women, however, bladder displacement is slight and the intact anterior vaginal wall is believed to provide support to the urethra (Watson & Williams, 1952). An erect lateral film in the IVU series is both a simple and cheap way of demonstrating the bladder position. Similarly, using the perineal approach for ultrasound is not difficult and may demonstrate an otherwise elusive bladder. Besides patients who have had abdomino-perineal excision of the rectum, other groups in which these modified techniques could be applied include those with major gynaecological exenterative surgery and panpro tocolectomies. Demonstration of abnormal bladder prolapse as the cause of urinary problems, especially in males, would be helpful in planning corrective surgery.
Case 2 A 68-year-old man presented with difficulty in micturition. He had intermittent poor stream and found that applying upwards pressure by hand to the perineum aided voiding. He had an abdomino-perineal excision for rectal carcinoma 3 years previously. Despite repeated attempts, the bladder could not be demonstrated by ultrasound with the transducer placed conventionally on the anterior abdominal wall. However, with the transducer placed perineally near the site of the former anal opening, the bladder was easily visualized (Fig. 3).
Discussion
In these two cases, inferior and posterior bladder prolapse is likely to have occurred owing to a combination of factors, such as severance of ligaments supporting the bladder, creation of a potential space by rectal excision and herniation of the bladder through a weakened or damaged pelvic floor. Indeed, post-mortem specimens have shown posterior displacement of the whole bladder, including the bladder base and prostate after abdomino-perineal excision. Buckwalter et al (1955) postulated that these changes, accompanied by angulation of the bladder neck and urethra, resulted in mechanical interference Vol. 65, No. 773
References BUCKWALTER, J. A., SHROPSHIRE, R. & JOINER, B. A.,
1955.
Morbidity of abdominoperineal resection. Surgery, Obstetrics & Gynecology, 101, 483-488. CHANG, P. L. & FAN, H. A., 1983. Urodynamic studies before and/or after abdominoperineal resection of the rectum for carcinoma. Journal of Urology, 130, 948-951. EICKENBERG, H., AMIN, M., KLOMPUS, W. & LICH, R.,
1976.
Urological complications following abdominoperineal resection. Journal of Urology, 115, 180-182. FOWLER, J. W., 1973. Bladder function following abdominoperineal excision of the rectum for carcinoma. British Journal of Surgery, 60, 574-576. FOWLER, J. W.,
BREMNER, D. N. & MOFFAT, L. E. F.,
1978.
The incidences and consequences of damage to the parasympathetic nerve supply to the bladder after abdominoperineal resection of the rectum for carcinoma. British Journal of Urology, 50, 95-98. LUPTON, E. W., 1986. Management of urinary outflow obstruction after pelvic surgery: a review. Journal of the Royal Society of Medicine, 79, 734-737. NEAL, D. E M PARKER, A. J., WILLIAMS, N. S. & JOHNSTON, D.,
1982. The long term effects of proctectomy on bladder function in patients with inflammatory bowel disease. British Journal of Surgery, 69, 349-352.
443
Technical notes RANKIN, J. T., 1969. Urological complications of rectal surgery.
WAITERS, G. R., BOKEY, E. L., CHAPUIS, P. H., MAHER, P. W.
British Journal of Urology, 41, 655-659. WATSON, P. C. & WILLIAMS, D. I., 1952. The urological complications of excision of the rectum. British Journal of Surgery, 40, 19-28.
& PHEILS, M. T., 1983. Urological complications following abdominoperineal excision of the rectum for carcinoma. Australasian & New Zealand Journal of Surgery, 53,445-447.
444
The British Journal of Radiology, May 1992
